As readers of SayAhhh! know, Georgetown University CCF and the University of North Carolina’s Sheps Rural Health Research Center has a joint project which has been tracking the role of Medicaid for rural areas and small towns. We recently updated our online data resource with county figures for 2015/2016, a time period during which the impact of the Affordable Care Act was growing – especially in states that chose to accept federal funding for the ACA’s Medicaid expansion. Two states which have been widely acknowledged as having some of the greatest success in dramatically reducing their uninsured rates are Kentucky and Arkansas – both of which adopted the expansion immediately under previous Governors. Both of these states are objects of intense interest in the Medicaid world today

As it turns out, those coverage gains have been especially important to families living in rural areas of those states. In December I blogged about the top ten rural counties[1] nationwide for the percent of adults covered by Medicaid. An eye-popping nine of those ten were in Kentucky!

Today I am looking at the top ten rural counties with the highest percent of kids covered by Medicaid. The results are also eye-popping – six of ten rural counties with the highest percent of children covered by Medicaid are in Arkansas. Phillips County, in the Arkansas Delta region comes in at #1 with an astonishing 83% of its kids getting their health coverage through Medicaid. Neighboring Lee County, also in the Arkansas Delta, is right behind with 82% of kids covered by  Medicaid. When we ran this data the first time for 2014/15 just two of the top ten counties with the most children covered by Medicaid were in Arkansas.

Arkansas and Kentucky’s quick implementation of the full Medicaid expansion had major positive benefits for families living in rural areas. In these states, kids benefited too – even though their eligibility didn’t change. This is because of the well-documented phenomenon we call the “welcome mat” effect – when parents are offered coverage their kids will benefit too.

From 2013 (i.e. pre ACA) to 2016 the overall rate of uninsured children in Arkansas declined from 5.5% to 3.6%. In 2016, Arkansas was doing better than the country with respect to its uninsured rate, which stood nationally at a record low of 4.5%.

For the earlier period (2014/15) six of the top ten top counties were in states that hadn’t expanded Medicaid (four counties in Mississippi alone). There are now only two counties in the top ten states that have not expanded Medicaid (Mississippi and Texas). We explored the value of Medicaid expansion to rural areas in our paper last fall – this new data provides additional evidence.

Needless to say, those who are carefully watching the fault lines in Medicaid today are aware that Arkansas is leading the charge to reduce enrollment by imposing difficult to comply with work reporting requirements that have led to over 18,000 losing coverage already.

And although children are “exempt”, children’s enrollment is declining rapidly as well. As my colleague Tricia Brooks blogged about yesterday, there are ominous signs indicating that the number of uninsured children is likely going to go up again this year. An “unwelcome mat” is at work. And what it is clear from our rural data is that those communities have a disproportionate stake in the future direction of Medicaid. Uninsured children and families have worse health outcomes and face far more financial barriers to care. For rural communities, which are struggling in many ways, the reversal of improvements in health coverage rates are just another blow to their efforts to improve the future prospects of their children.

[1] Our Rural Health Research Project defines rural counties includes those with small towns of 50,000 or less.